Unstable fractures will almost always require surgical stabilisation. The electronic databases PubMed, Scopus, and Embase were interrogated using the search terms bimalleolar or trimalleolar and fracture. Fractures with more injured parts may be more swollen and may require more incisions. The authors conducted a retrospective review of prospectively collected data. Validation of the American College of Foot and Ankle Surgeons Scoring Scales. Concerning unstable fractures of the ankle, Day described excellent or good outcomes in 64% of cases and fair or unsatisfactory in 36%.43. 562 Fracture, sprain, strain and dislocation except femur, hip, pelvis and thigh with mcc; 563 Fracture, sprain, strain and dislocation except femur, hip, pelvis and thigh without mcc; 963 Other multiple significant trauma with mcc Any bi- or trimalleolar fracture should be considered unstable because of the disruption of the bony architecture on both the medial and lateral side of the joint. When a bone breaks or cracks, the injury is called a fracture. Since physical . Overall, surgeons should be considering the axis of the legs before choosing to surgically treat, and eventual causes for deformity should be investigated (rickets, neurofibromatosis, etc.). Only studies with outcomes scores were deliberately included to better compare results and to avoid vague or casual data. The physical exam helps to determine the amount of laxity of the ankle joint, pain over the ankle, peroneal tendon pain/swelling, in addition the alignment of the . Noh JH, Roh YH, Yang BG, Kim SW, Lee JS, Oh MK. Ankle fractures are typically very painful and obvious if there is a dislocation (ankle joint out of place) or an open wound. Surgery for an ankle fracture is done if the bones in the ankle are unstable and need more support to heal. Ankle fractures can be broadly divided into stable or unstable injuries. In general, it takes at least 6 weeks for the broken malleoli to heal. The only time that unstable trimalleolar fractures are left to heal on their own is when surgery would pose too big of a threat to the patient due to health concerns or other potential complications. Unstable ankle fracture: the stability or structure of the ankle joint is affected by the break. Advances in the Surgical Management of Ankle Fractures. VAS scale was reported in five studies, SMFA in two studies, while AFSS score, BairdJackson score, and Phillips score in one study. Fixation with bioabsorbable screws for the treatment of fractures of the ankle. Short musculoskeletal function assessment questionnaire: validity, reliability, and responsiveness. Those were the challenge to fix smaller fragments of the PM, the difficulty to judge the quality of reduction and direction of the screws under fluoroscopy, and not always being able to achieve intrinsic stability of fixation by screws alone when the injury revealed a vertical shear component.16 Kalem observed a non-statistically worse reduction in the P-A screw group compared to the A-P screw group.37 Vidovic reported no difference in complication rate between A-P fixation and P-A fixation.39 Regarding osteosynthesis by buttress plates or P-A screws, the posterolateral or posteromedial approach played a significant role in obtaining good outcomes.16 Posterior fixation provided better anatomical reduction under direct visual control, also for small or medium-sized fragments, while interfragmentary compression and biomechanical stability are improved with a buttress plate able to resist vertical shear.24,28,39,45 However, fixation through a posterior approach could also reveal some technical challenges, related to prone or lateral positioning (and consequent difficult fixation of medial malleolus), possible danger or injury of the sural nerve, and to surgery duration, because of the lesser familiarity with this technique among the surgeons.16,45, Zhong compared results deriving from posterolateral and posteromedial approaches. Reduction is usually done after pain medications have been given, and these can include oral, intravenous, or local pain medications. All the outcomes of the thirty-three selected studies were analyzed. Unable to load your collection due to an error, Unable to load your delegates due to an error. C1: diaphyseal fracture of the fibula, simple; C2: diaphyseal fracture of the fibula . Bucholz RW, Henry S, Henley MB. Unstable fractures are unlikely to heal correctly on their own. These elements in your joint not only help it move, they work together to promote stability. The most common malleolus fracture happens at the fibula. Are outcomes of bimalleolar fractures poorer than those of lateral malleolar fractures with medial ligamentous injury? Figure 3. After this initial exam, x-rays are usually performed to help define the bony injury and some form of splint may be applied. Typically these injuries are . Given the instability, they often require surgical treatment, but literature scarcely reports on the outcomes of their management. The size of the PM is crucial: the greater size of the fragment, the higher risk of talar posterior shift during dorsiflexion. Schedule an appointment to see an Emory specialist today. Ankle Sprain. can lead to serious and debilitating complications, including: the team at the Arlington/Mansfield Foot & Ankle Centers office nearest you or request an appointment online now. Certain fracture patterns are stable and are thus treated without surgery similarly to ankle sprains. Even small. If you struggle with pain or lack of mobility in your ankle, you may wonder if a total ankle replacement is right for you. After fixation of the fibula fracture, the arthroscopic drive-through sign should be performed. Not getting proper treatment for ankle fractures can lead to serious and debilitating complications, including: With any ankle injury, its important to have your ankle evaluated by trained ankle specialists to ensure you get the right diagnosis and care to get you back on your feet soon without complications down the line. To best describe the degree of injury, we describe ankle fractures according to the number of malleoli fractured. Intramedullary fixation of distal fibular fractures: a systematic review of clinical and functional outcomes. Diagnosis can be made clinically with swelling and ecchymosis of the ankle and pain with range of motion. gently hold an ice pack (or a bag of frozen peas) wrapped in a towel on your ankle for 15 to 20 minutes every 2 to 3 hours. You may be instructed in home exercises at this point, and given a fracture boot to allow easy removal for bathing and range of motion exercises. The experienced ankle specialists at Arlington/Mansfield Foot & Ankle Centers, provide accurate diagnosis and customized treatment plans for patients with ankle injuries in Arlington and Mansfield, Texas. The fibular nail is an alternative method of fixation requiring a minimal incision and tissue dissection, and has the potential to reduce the incidence of complications. Intramedullary fixation of fibula fractures: A systematic review. 2021 Apr;33(2):104-111. doi: 10.1007/s00064-021-00702-1. Lateral: Best for posterior malleolar fractures. An overview on the treatment and outcome factors of ankle fractures in elderly men and women aged 80 and over: a systematic review. Three major bones (fibula, talus, and tibia) make up the structure of your ankle along with the different ligaments and tendons that help it move. Swiontkowski MF, Engelberg R, Martin DP, Agel J. Strains range from minor to severe, and can sometimes result in a tear. They are associated with pain, resulting in it being very difficult or even impossible to walk on the ankle. The Swedish version of OMAS is a reliable and valid outcome measure for patients with ankle fractures. 2022 Jul 26. doi: 10.1007/s00167-022-07058-4. Home care includes things like protecting the injured ankle, using crutches or other devices to help immobilize the joint, mild compression, elevation, and apply cold packs or ice for 15-20 minutes every 2 hours. Preexisting deformities of the lower extremities and ankle ROM must be considered. This is because there is very little tissue (fat, muscle, fascia) between the skin and the bone around the ankle. Phillips score: excellent or good 64%, fair or unsatisfactory 36%. Surgeon should consider factor may influence functional outcomes. 2015 Nov;46 Suppl 6:S125-9. An official website of the United States government. The experienced. Quinn TM, Huselmann HJ, Shintani N, Hunziker EB. Please enable it to take advantage of the complete set of features! Each of these bones has critical parts that work to hold the ankle together while still allowing motion. A prospective, randomized study of the management of severe ankle fractures. There is variation in UK practice around weight-bearing instructions after operatively managed ankle fracture. Different types of ankle fractures Fibula Only Fracture (lateral malleolus fracture) Surgical fixation of unstable ankle fractures should always be performed within the first 48 hours from the trauma, preventing instability and post-traumatic osteoarthritis. The most controversial ankle fracture is the Weber B fracture in which the fibular (or lateral malleolar) fracture begins at the level of the ankle mortise and extends proximal and lateral. After the abstracts were reviewed, 109 studies were excluded for the same reason. Foot Ankle Int. While most simple ankle fractures heal very well, more significant injuries may have long-term issues and can include stiffness, soreness, and an inability to regain full, pre-injury motion and function. MeSH We reviewed the results of 105 patients with unstable fractures of the ankle that were fixed between 2002 and 2010 using the Acumed fibular nail. The stability related to posterior malleolus in ankle fracture. The site is secure. Post-traumatic osteoarthritis was described in 7.6% to 44% after unstable ankle fractures.7,21,22,25,45 The risk of post-traumatic osteoarthritis depends on the size of fragments (small 16%, medium 48%, large 54%; p=0.006).7 Osteoarthritis occurred more frequently when there was a postoperative step-off 1mm on the cartilaginous surface.25 OConnor reported wider osteoarthritis after fixation with a post-operative plate than AP screw (37.5% vs 20%).45 Regier found osteochondral lesions in 40.4% of the patients. Operative treatment of ankle fractures: a minimum ten-year follow-up. Functional treatment and early weightbearing after an ankle fracture: a prospective study. The presence and inclusion of only six prospective studies was the main quality deficiency of the present study. A prospective randomised controlled trial of the fibular nail versus standard open reduction and internal fixation for fixation of ankle fractures in elderly patients. Surgical incisions around the ankle are at higher risk for wound complications than skin in other areas. Hence, the author recommends syncing theis of all the fractures.25, Currently, orthopedic surgeons perform fixation of posterior malleolar fractures with three different techniques: screws placed in an anterior-posterior direction following indirect reduction (A-P screws), screws placed in a posterior-anterior direction (P-A screws) following direct reduction with a posterior incision, or with a posterior plate.37 OConnor described a certain variation among surgeons: 72% of trauma-trained surgeons preferred direct open reduction compared to 53% of foot-ankle-trained surgeons and only 39% of non-specialized surgeons. An ankle fracture (or broken ankle) means that one or more of the ankle bones are broken. Lateral malleolus closed reduction and internal fixation with intramedullary fibular rod using minimal invasive approach for the treatment of ankle fractures. Performing early surgery to restore joint stability should be also more effective in inhibiting the progression of chondrocyte damage, potentially moderating the pathological cascade to post-traumatic osteoarthritis. (3) What factors influence the outcomes? Early weight-bearing may reduce reliance on health services, time off work, and improve . When 2 malleoli are fractured, the injury is called a bimalleolar ankle fracture and when 3 malleoli are fractured, the injury is called a trimalleolar ankle fracture. Two authors (LM, LCZ) reviewed the titles: 427 studies were excluded because they did not meet the inclusion criteria. 2016 Sep;98-B(9):1248-52. doi: 10.1302/0301-620X.98B9.35837. . Because the joint is unstable, it is susceptible to damage and early ankle arthritis if left untreated. The .gov means its official. Between October 2000 and November 2006, 347 patients who underwent surgical repair of an unstable ankle fracture were enrolled in a prospective database. Karaca S, Enercan M, zdemir G, Kahraman S, obanolu M, Kkkaya M. Importance of fixation of posterior malleolus fracture in trimalleolar fractures: A retrospective study. eCollection 2022 Jul. come in many varieties, from a slight break in one bone that doesnt prevent you from bearing weight on it, to severe fractures that you dont put weight on it for months and may require surgery. Widening of ankle mortise caused by syndesmosis injury leads to lateralization of vertical mechanic forces. 2021 Apr 24;18:136-143. doi: 10.1016/j.jcot.2021.04.020. 2022 Jul 9;14(7):e26675. Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J. Methodological index for non-randomized studies (MINORS): development and validation of a new instrument. The final review included 33 studies. Outcomes of operative treatment of unstable ankle fractures: a comparison of metallic and biodegradable implants. doi: 10.7759/cureus.26675. Miller AN, Carroll EA, Parker RJ, Helfet DL, Lorich DG. Zhang L, Xu J, Tang X, Zhou X, Li B, Wang G. Front Bioeng Biotechnol. Epub 2014 Oct 11. After the duplicates were eliminated, 641 original articles remained. Both the bones end with a bump on inner and outer . In some cases, the bones of the ankle may poke through the skin. An untreated strain may affect your ability to stand and walk later, and it can increase your risk for future strains. At Arlington/Mansfield Foot & Ankle Centers Ankle, your provider determines the nature and extent of your ankle injury through a physical evaluation and imaging studies (e.g., ultrasound, digital X-ray, MRI, CT scan) if required. OConnor TJ, Mueller B, Ly TV, Jacobson AR, Nelson ER, Cole PA. A top screw versus posterolateral plate for posterior malleolus fixation in trimalleolar ankle fractures. The most standardized and reliable scores and questionnaires reported are the OMAS score, the AOFAS score, VAS score, and SMFA score.310 As far as the outcomes of the treatment of unstable ankle fractures are concerned, most studies reported excellent or good results with these scores.14,16,1821,2426,2934,39,43 Surgical fixation is mostly preferred over conservative treatment as it consistently returns better outcomes.7,13,17,26,32,38,42 Particularly, surgery allows for shorter immobilization and earlier weight-bearing leading to better functional scores and higher rates of return to normal life.19,26,34 As a result of this review, surgical treatment for all the unstable fractures is recommendable to restore the anatomy, function, and stability, and to reduce the risk of complications as post-traumatic arthritis was demonstrated to develop faster after conservative treatment.14,21,37,45, Interesting histological studies were performed by Tochigi and Quinn.46,47 The former demonstrated that post-traumatic osteoarthritis commonly occurred in multi-fragmentary fractures because of the death of chondrocytes near the fracture line.46 The cells disfunction propagates to the surrounding non-fracture areas within the first 48 hours, and its extent is related to the comminution degree, the overall length of the fracture lines, and to the intensity of the applied mechanical forces. They are the extension of a lateral collateral ligament injury. J Clin Orthop Trauma. Scholastica Support. , but they more commonly result during sports and fitness activities, after tripping or falling, and when you twist your ankle during any activity. Concerning PM fractures, successful functional and radiological outcomes have been clearly demonstrated to be related to fixation.7,14,16,21,38,40,45 ORIF was traditionally indicated in case of fragment size greater than 25%-33% of the articular surface, measured on plain films or CT scans. Untreated sprains can lead to a chronically unstable ankle joint. In an unstable ankle fracture, the joint will not support weight-bearing without displacing. The stability related to posterior malleolus in ankle fracture. Setting: Moreover, selecting the approach and hardware for the PM should be depending on the pattern of the fracture and on the surgeons preference and experience. Fixation with P-A screws or posterior plates is advisable because they provide better anatomical reduction under direct control, also for small or medium-sized fragments, and implants can resist shear forces.16,24,39,42,45 On the other hand, fixation with A-P screws shows some disadvantages such as the challenge to fix small fragments of the PM, the difficulty to judge the reduction and direction of the screws under fluoroscopy, and reduced intrinsic stability of fixation.16,37 However, since no significant differences in complications were reported between A-P fixation and P-A fixation,39 the latter should be recommended only to experienced surgeons because of the difficulties associated with one or lateral positioning, demanding fixation of medial the malleolus and possible injury of the sural nerve.16,45. The picture in Figure 4 shows a patient with a fractured ankle that is dislocated and pushing against (tenting) the skin. For help with an ankle injury, contact the team at the Arlington/Mansfield Foot & Ankle Centers office nearest you or request an appointment online now! Your surgical team will usually see you to follow-up around 7 to 14 days after surgery. If the ankle is not dislocated and it is not obvious if the fracture is stable or not, a stress x-ray may be needed. A fracture can be caused by a fall, a blow to the . Ankle Fracture Study For their study, researchers analyzed the outcomes of patients undergoing either casting or surgery for an unstable ankle fracture. Depending on your needs, your surgical team may choose to initiate formal physical therapy at this time or delay physical therapy until a later date. The possibility to compare functional outcomes is crucial: for this reason, patient-reported scores and questionnaires were developed. If you have diabetes, part of managing your condition means taking care of your feet. Bimalleolar ankle fracture is called Pott's fracture. Since there are injuries to both sides of the ankle, bimalleolar fractures are frequently unstable, and the ankle is often dislocated. Cook JJ, Cook EA, Rosenblum BI, Landsman AS, Roukis TS. Open reduction and internal fixation (ORIF) is a type of surgery used to stabilize and heal a broken bone. The results are divided into excellent with more than 95 points representing the best possible outcome, good with 90 to 95 points, fair with 80 to 89 points, and unsatisfactory with less than 80 points. Initially, cell necrosis occurs at the fracture line, followed by delayed apoptosis in non-fracture areas due to excessive acute mechanical stresses and the cytotoxic effect of biomechanical mediators (reactive oxygen species, matrix-damaging enzymes, inflammatory cells, and cytokines).46 Post-traumatic events occur mostly in the transitional zone of cartilage, while cell volumes per volume unit and cell surface areas per volume unit are both altered mostly on convex surfaces of the ankle.47. A Large Animal Model for Orthopedic Foot and Ankle Research. This condition increases your chances of developing conditions, such as: Untreated sprains may also make it feel as though your ankle is always about to give out. Gehr J, Friedl W. Intramedullary locked fixation and compression nail (IP-XS-Nail): treatment of ankle joint fractures. A Tension-Band Wiring Technique for Direct Fixation of a Chaput Tubercle Fracture: Technical Note. For this systematic review we asked: (1) What are the outcomes in treatment of unstable ankle fractures? Unstable fractures require surgery, most often an open reduction and internal fixation (ORIF), which is usually performed with permanently implanted metal hardware that holds the bones in place while the natural healing process occurs. Search terms for bimalleolar or trimalleolar fractures of the ankle. A fracture is synonymous with a break. Objective: Ankle fractures are often combined with syndesmotic instability, requiring reduction and stabilization. Unable to load your collection due to an error, Unable to load your delegates due to an error. A proposal and validation. Aftercare following syndesmotic screw placement: a systematic review. Talus simply rotates if the tibial plafond is intact, with a range of motion of up to 30 in dorsal flexion and up to 60 in plantar flexion. Sorry, something went wrong. ), and daily life activities (work, sports, etc.). Radiographically, 18 of 144 (13%) syndesmotic screws were noted to be broken on follow-up radiographs, eight of which were subsequently removed. Xing W, Wang Y, Sun L, et al. sharing sensitive information, make sure youre on a federal This means that the fracture disrupts the structural integrity of the ankle (joint). Widening of ankle mortise (Weber C and some Weber B Fractures) Consistent with unstable Ankle Fracture; Consider performing on stress view in unimalleolar Fractures; Lateral talus displacement at rest, on gravity stress or external rotation (Weber B) Suggests Deltoid ligament rupture (and unstable Fracture) sharing sensitive information, make sure youre on a federal Ankle fractures involving the fibula proximal to the distal tibiofibular syndesmosis. stop any bleeding - put pressure on the wound using a clean cloth or dressing. Clipboard, Search History, and several other advanced features are temporarily unavailable. Chronic Ankle Instability. Tejwani NC, McLaurin TM, Walsh M, Bhadsavle S, Koval KJ, Egol KA. You might need this procedure to treat your broken ankle. Bethesda, MD 20894, Web Policies Tubular vs Profile Plate in Peroneal or Bimalleolar Fractures: is There a Real Difference in Skin Complication? This instability increases your risk of re-injuring your ankle. (2) What are the usual complications of treatment in unstable fractures? In the ankle, three different bones can be fractured: The tibia This is the larger of the two bones in the lower leg. All patients were followed and evaluated at 3, 6, and 12 months with clinical and radiographic examination as well as functional status (Short Musculoskeletal Functional Assessment, American Orthopaedic Foot and Ankle Society). The good news is that the foods you eat can help you manage this troublesome condition and reduce uncomfortable flare-ups. Their distal ends form a mortise that encompasses the talus, which is a bone in the foot (see Figure 1). Ankle fractures occur in the medial or posterior malleolus of the tibia and/or lateral malleolus of the fibula. We reviewed the results of 105 patients with unstable fractures of the ankle that were fixed between 2002 and 2010 using the Acumed fibular nail. Noh JH, Roh YH, Yang BG, Kim SW, Lee JS, Oh MK. Epub 2021 Mar 16. Ankle Sprains are very common twisting injuries to the ankle that are the most common reason for missed athletic participation. Concerning validated functional scores, OMAS score (n=13) and ankle-hindfoot AOFAS score (n=21) were the more frequently used. Clipboard, Search History, and several other advanced features are temporarily unavailable. This instability increases your risk of re-injuring your ankle. Does functional outcome depend on the quality of the fracture fixation? ankle fracture. Accordingly, for posterior fragments of the same size, the larger the dorsal flexion angle (Figure 3, angle) the higher the risk that the talar apex could not be contained by the tibial abutment because of talar roto-translation, generating instability. Ankle fractures, known more commonly as a "broken ankle", happens when there is a break in one or more of the bones that make up the ankle joint. Simanski CJ, Maegele MG, Lefering R, et al. Although fractured ankles are an injury seen in almost every age, it is becoming more prevalent in older, more active generations. In unstable ankle fractures, the ankle joint itself is displaced or can be displaced when it is subject to normal forces. A Systematic Review of the Outcome Evaluation Tools for the Foot and Ankle. eCollection 2022. Thus, Roberts recommended that ankle fractures should be treated only by skilled surgeons.13 The same results were found by Tewjani.32 Petruccelli assessed outcomes comparing fixation with LCP and conventional one-third tubular plate: no significant differences in radiographic bone union, time of fracture healing, or wound complication rate were found.44, Some studies assessed the correlation between functional scores and immobilization. Injuries can result from anything from an unforeseen mis-step, to falling and rotating the ankle to the point of muscle strain, tendon tear, or bone break. Excellent and good results were 93.3%.18. Epub 2015 Nov 12. Please try again. Strains range from minor to severe, and can sometimes result in a tear. What is a distal fibula fracture? This site needs JavaScript to work properly. The ankle is a synovial, hinge joint that is comprised of three articulating bones, three groups of ligaments and three supporting tendons. The shorter immobilization, the better the outcomes: early rehabilitation significantly improves activity limitation and ankle range of motion, and reduces postoperative pain.19,26 These results were demonstrated in a prospective study by Simanski: early rehabilitation combined with weight-bearing was substantial in reducing the duration of the hospital stay and the return-to-work time.42, Successful functional and radiological outcomes were clearly demonstrated to be related to the fixation of the posterior malleolar fractures.7,14,16,21,38,40,45 The target of osteosynthesis is twofold: first, eliminating the eventual instability generated by the displacement of the PM; second, achieving an anatomical reduction of the articular surface in order to minimize posttraumatic osteoarthritis.14,21,37,45 Operative treatment improved functional outcomes: Tosun demonstrated lower AOFAS scores after conservative treatment compared to surgery (AOFAS 70 vs 92, p<0.001).38 Moreover, dorsiflexion was found to be significantly increased after fixation of the PM: the synthesis restored appropriate tension and integrity of the posteroinferior tibiofibular ligament.20 DeVries reported no significant difference in 13yrs-term outcomes between conservative and surgical groups. Therefore, it is clear how instability devastates the joint cartilage and why we may want to consider a first 48hrs golden time to limit its disruption. Of the remaining 105 articles, 76 were excluded after evaluation of the full text. J Foot Ankle Surg. Epub 2014 Apr 4. Deltoid ligament repair versus syndesmotic fixation in bimalleolar equivalent ankle fractures. Keep reading to learn what you need to know. may affect your ability to stand and walk later, and it can increase your risk for future strains. All content 2022 Orthopaedic Trauma Association unless otherwise noted. This information is important for patient counseling to manage expectations regarding outcomes after injury. The lateral malleolus is at the end of the fibula, a smaller bone in the leg. A fracture may also damage your ligaments. Trimalleolar fracture is a specific injury in the ankle, where three areas known as the malleoli break simultaneously. 2022 Jul 27;58(8):1005. doi: 10.3390/medicina58081005. Kalem M, ahin E, Songr M, Keser S, Kinik H. Comparison of three posterior malleolar fixation methods in trimalleolar ankle fractures. Carter TH, Mackenzie SP, Bell KR, et al. trend toward surgical fixation for most unstable ankle fracture patterns despite patient age. The bony parts of the fibula and tibia are called malleoli (singular = malleolus). Open reduction and internal fixation of posterior malleolar fractures using the posterolateral approach. and transmitted securely. Gupta S, Virk JS, Malhotra A, Garg SK. Smoking has been shown to slow healing after ankle fracture surgery, so if you smoke, you should not do so at this time. An unstable ankle fracture can occur when an injury compromises the integrity or stability of the ankle joint. Each ankle fracture needs specific rehabilitation based on its injury type and fracture stability. 4 Excellent results are predicted with open reduction and internal fixation of unstable ankle fractures. There was a greater percentage of Type C fractures requiring syndesmosis stabilization, whereas Type B fractures were less likely to require syndesmosis stabilization (P = 0.001) At 6- and 12-month follow up, there was a clear difference in outcome based on American Orthopaedic Foot and Ankle Society and Short Musculoskeletal Functional . When surgeons think about ankle fractures, we think in terms of these bony parts and ligaments. Unstable ankle fractures are generally treated by ORIF. Request an appointment 617-724-9338 About our center Pulling Fractures of the Fibula (Avulsion or Weber A type fractures). Also, to avoid false illusions concerning outcomes, the patient should be given the information that post-traumatic osteoarthritis is the most frequent complication, correlating more to the complexity of the fracture pattern (trimalleolar, large-sized posterior fragment) than to the treatment itself.7,13,21,22,25,32. Three bones make up the ankle joint. Mingo-Robinet J, Lpez-Durn L, Galeote JE, Martinez-Cervell C. Ankle fractures with posterior malleolar fragment: management and results. During this time, you cannot put weight on your ankle. 2021 Aug 10;6(8):692-703. doi: 10.1302/2058-5241.6.200138. HHS Vulnerability Disclosure, Help Stability of Weber B Fractures. Figure 1: Optimal ankle positioning with gravity stress testing. Kamin K, Kleber C, Marx C, Schaser KD, Rammelt S. Oper Orthop Traumatol. eCollection 2022. Ankle injuries play a major part in functional impairment after multi or polytrauma thereby necessitating a detailed evaluation. , provide accurate diagnosis and customized treatment plans for patients with ankle injuries in Arlington and Mansfield, Texas. The normal tibiotalar axis passes through the center of the tibial plafond and the talar apex, in a lateral view. Objective: Before Figure 1. Scores are divided into excellent (96 to 100 points), good (91 to 95 points), fair (81 to 90 points,) and poor (80 or fewer points).8 Xing reported a mean Baird-Jackson score of 96.2 points; twenty-two cases were excellent, six cases were good, and two cases were fair. Ankle fractures are unstable if the injury allows the talus to be move within the mortise (Figure 4). (4) What about the role of the posterior malleolus? Federal government websites often end in .gov or .mil. After surgery, you will most likely be in a plaster splint or fracture boot. Step 1 Exclusion criteria were fractures in children, fractures involving joints other than the ankle (tibial pilon, Lisfranc, calcaneus), previous arthroscopy of the ankle, isolated repair of the deltoid ligament, as well as case reports and reviews, studies on animals/cadavers, epidemiologic studies, surgical technique notes, or conservative only treatment descriptions. Gout is a form of arthritis that usually causes painful symptoms in your big toe. Cell and matrix morphology in articular cartilage from adult human knee and ankle joints suggests depth-associated adaptations to biomechanical and anatomical roles. If the lateral ligaments are ruptured then the ankle may feel weak. In 1985 Phillips proposed a 115-points system to document subjective and functional outcomes, including arthritis grading.9 In this system, overall scores from 110 to 115 were classified as excellent, 96 to 109 as good, 70 to 95 as fair, and less than 70 as poor. Kukk A, Nurmi JT. Petruccelli R, Bisaccia M, Rinonapoli G, et al. An ankle fracture can involve several fractures, that forces the ankle out of place and may require months to fully heal. Evidence-Based Medicine Resource List Overview, OTA SOMOS Military Traveling Fellowship Program, IOTA Special Issue: Orthopaedic Trauma Care: Global Approaches During a Pandemic, Research Volunteer Mentoring Program Overview, OTA Support of Federal Grant Applications, OTA Kathy Cramer Young Clinician Scholarship, The Issue of the Surprise-Billing Rules in Plain English, Disaster Management and Emergency Preparedness, Disaster Management and Emergency Preparedness Overview, OTA Orthopaedic Trauma References & Resources, Brendan M. Patterson, MD, OTA President - Press Release, Lifetime & Planned Giving Donors Overview, Corporate & Foundation Donor Archive Overview, Exhibits & Marketing Partnerships Overview, Sponsorship Right of First Refusal Guidelines, Video Library: Annual Meeting & Conferences, American Orthopaedic Foot & Ankle Society. The fracture may involve the ligaments that hold the joint together, the joint surfaces themselves or a combination of both. Therefore, the typical treatment is to surgically repair the fracture to stabilize the ankle joint. 2013 Jul-Aug;52(4):491-4. doi: 10.1053/j.jfas.2013.03.032. Irwin TA, Lien J, Kadakia AR. An ankle injury happens whenever the ankle is rolled or twisted out of its normal position, resulting in pain and swelling. The vault is contained by the tibial abutment, limited by anterior (B in Figure 3) and posterior (C in Figure 3) edges. Tags. It is called a lateral (outside of the ankle) malleolus fracture and is depicted in Figure 5. Surgeons should assess the pattern of fractures complexity as the comorbidities of the patients: the outcomes are worse in the more complicated ones (Danis-Weber Type C, fracture-dislocation, soft tissue injury) even if surgical fixation is performed lege artis.14,15,23,37 Worse outcomes have been found in older, fatter patients, with class higher operative risk, especially if affected also by dementia.14,34 Thus, the importance to inform the patient preoperatively about his condition and the really achievable results is crucial. doi: 10.1016/j.otsr.2014.03.005. The worse the injury, the more likely it will be unstable. Theres no doubt having a sprained ankle is a pain! official website and that any information you provide is encrypted Three hundred forty-seven patients met the inclusion criteria and had 1-year minimum follow up. MINORS = Methodological Index for Non-randomized Studies. Ankle fractures can be classified by the mechanism that caused that fracture, or the number of locations that have fractured, or by the location of the fracture of the fibula (the bone on the outside of the ankle) relative to the ankle joint line. Would you like email updates of new search results? Patients: PRINCIPLES OF MANAGEMENT Mechanism of Injury The vast majority of ankle fractures are sustained via a rotational mechanism. You may be sent home with crutches or some other form of assistive device to help keep weight off your ankle. An official website of the United States government. For example, a transverse fracture is produced by traction from . Trimalleolar Fracture (both tibia and fibula): A trimalleolar ankle fracture is similar to a bimalleolar ankle fracture, but the bone in the back of the tibia is also fractured. The quality of the studies was evaluated with the Methodological Index for Non-randomized Studies (MINORS) questionnaire. The arthroscopic shaver will be easily inserted between the medial malleolus and the talar dome, indicating a positive drive-through sign. Knee Surg Sports Traumatol Arthrosc. Ankle joint dislocation treating dislocated trimalleolar fractures accompanied with the complex posterior malleolus fracture without separation of the tibiofibular syndesmosis. Negative prognostic factors in surgical treatment for trimalleolar fractures. While you can avoid all injuries, you can reduce your risk by keeping your feet and ankles healthy with these tips. The research questions, inclusion, and exclusion criteria were decided a priori. These normally require surgery. Strains, sprains, and fractures can all have similar symptoms, making it difficult to tell which you have without a. results from a stretched or torn muscle or tendon, which is the thick tissue that connects your muscle to the bone. What are the dangers of an untreated ankle injury? However, although the outside bone is fractured, the ankle joint itself remains well positioned and stable. Selective fixation of the medial malleolus in unstable ankle fractures. Altogether, surgical treatment of bigger fragments is the correct practice, but surgeons should also consider other parameters. doi: 10.1016/j.injury.2015.10.062. Usually, the displacement of the posterior fragment is cranial, causing no mechanical impingement onto talar rotation during dorsal and plantar flexion (Figure 3). A Retrospective Study in Three Level I Trauma Center. Unstable injuries benefit from surgery to provide stability to the ankle joint as a whole and to the individual fractured parts. It may also cause ankle instability; In some cases, bones around the ankle may be broken or dislocated, or the smooth surface of the ankle bone (talus) and tendons around the ankle joint may be damaged causing osteochondral injury of the ankle; Ankle instability. J Orthop Traumatol. The risk of developing an osteochondral lesion increased up to 5.6% when the AOFAS score decreased by one point (p=0.01).22, Wound infections were pretty common. This could mean a plate and screws, just screws, a nail, or just suture. Superficial infections were reported in 1.44 to 15.56% of patients.15,19,20,24,29,31,32,37,39,40,44 Deep infections were described in 1.9 to 13% of population.19,21,44 Wound dehiscence was in 1.8 to 2% of cases30,44 while wound reactions to implant in 5.0 to 7.2%.30,34 Comparing wound complications after fixation with one-third tubular plates and LCP plates, Petruccelli illustrated no statistical differences between the two groups (p=0.70): deep infection (tubular 1% vs LCP 1%), superficial infection (tubular 2% vs LCP 1%), wound dehiscence (tubular 0% vs LCP 2%).44, Delayed union was reported in 0 to 15% of patients.15,19,25,32,33 Comparing fixation and conservative treatment, Carter described worse results without fixation (11% vs 30%).17 Delayed union after conservative treatment was reported in 10.0% of patients by Hoelsbrekken.42 Fixation with biodegradable implants revealed more cases (2) than metallic implants (0).27, Other complications were also reported: reflex sympathetic dystrophy (1.5 to 15%),15,29,34,37 deep vein thrombosis and pulmonary embolism (0.34 to 6%),30 sural nerve injury (1.1 to 4%),21,24,36 fracture displacement (0.05-8.0%),33,40 failure of biodegradable screw (0.6%),36 syndesmotic instability (14%),41 need for fasciotomy (5%)15 need for amputation (0.16%) and mortality (1.07%).31, Failure of implant necessitating revision was described in 0.82 to 10% of cases.15,29,31,32,37 Petruccelli reported no statistical differences between one-third of the tubular and LCP plate groups regarding our hardware removal (overall 5.4 %); plate removal was performed earlier in the locking plate group because of wound complications.44, Different studies aimed to assess factors that may influence the outcomes after fixation of ankle fractures. Would you like email updates of new search results? 5 Surgeries Used to Treat Ankle Arthritis Some are patient-related, like age, BMI, or associated comorbidities, while others are depending on the complexity of the fracture pattern or the presence of a fracture-dislocation. This is because diabetes can cause foot complications including diabetic foot ulcers. 2012 Nov 21;94(22):e166. These elements in your joint not only help it move, they work together to promote stability. Each author certifies that he/she has no commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) Impact of trimalleolar ankle fractures: how do patients fare post-operatively? The inclusion criteria were: treatment of bimalleolar/trimalleolar fractures in adulthood, outcomes reported with scoring systems accepted in the literature. Four articles were added to 29 eligible studies from their references, for a definitive total of 33 studies enrolled in the final analysis and qualitative assessment (Table 2). Heres what you need to know. Ankle fracture is defined as unstable when the integrity or stability are compromised: it occurs in case of disruption of the restraining structures on the medial side (deltoid ligament - medial malleolus), lateral side (lateral ligaments - fibular malleolus), distal tibiofibular syndesmosis and/or posterior malleolus (PM). The deltoid ligament is found on the inner part of the ankle and provides the majority of the stability of the ankle. While most ankle fractures heal well, some may develop post-traumatic arthritis, with increasing pain and stiffness. The term functional ankle instability, on the other hand, refers to a subjective condition in which the ankle only feels as though it were unstable. 2014 Jun;100(4 Suppl):S255-9. Disclaimer, National Library of Medicine Complication rates following open reduction and internal fixation of ankle fractures. Heres what you need to know. Academic medical center. This means that the aforementioned processes (cell apoptosis, cartilage degeneration, matrix damage) develop not only nearby the fracture lines but also in areas not directly involved by trauma. Posterior malleolar fractures should be fixed regardless the size, considering some individual factors. Search terms for bimalleolar or trimalleolar fractures of the ankle. Thats why not jumping back into exercise too soon is essential. A Novel Adjustable EndoButton Fixation Assisted by 3D Printing Technology for Tibiofibular Syndesmosis Injury: A Biomechanical Study. Baird RA, Jackson ST. Fractures of the distal part of the fibula with associated disruption of the deltoid ligament. Fate of the syndesmotic screw--Search for a prudent solution. Outcome of surgical management of bimalleolar fractures in adults. Portable dynamic ultrasonography is a useful tool for the evaluation of suspected syndesmotic instability: a cadaveric study. Patients who required syndesmotic stabilization in addition to malleolar fracture fixation had poorer outcomes at 12 months compared with patients who required malleolar fracture fixation alone. In North America, most surgeons would agree that markedly unstable definitely unstable ankle fractures are best treated surgically.Therefore, Weber B . Strains, sprains, and fractures can all have similar symptoms, making it difficult to tell which you have without a medical evaluation. It may give way easily, without warning, particularly on uneven ground. This condition often develops after repeated ankle sprains. Nonetheless, the author concluded that ORIF was essential because unstable and unreduced frafracture-dislocations worse long-term outcomes.7, A matter of debate is still represented by the size of the fragment to treat: most studies recommended internal fixation for posterior malleolar fractures affecting 25% to 33% of the articular surface measured on the plain radiographs or CT. Excellent or good only outcomes were reported by Gupta (50% excellent, 50% good), Vem (60% excellent, 26.6% good), Choi (24% excellent, 48% good), Kukk (mean 86.0 points), Mingo (excellent or good 53.85%), Gehr (58.6% excellent, 33.3% good), Simanski (mean 90.0 points).16,19,24,29,30,33,34 Fair outcomes were reported by Testa (mean 75.3), Hong (mean 78.3),and Gehr (5.5% of cases).14,26,33 Conservative and surgical treatments were compared by means of the OMAS scale in some studies.13,17,42 Surgery tended to achieve better results: Roberts reported an OMAS score of 71.2 after fixation versus 57.3 after conservative treatment; Carter 85 points after fixation and 80 points after cast; Hoelsbrekken 81 points after surgery, 80 points after conservative treatment.13,17,42, Testa compared OMAS score based on the pattern of fracture, reporting a mean of 78.65 points in Danis-Weber Type B fractures and a mean of 69.72 points in type C fractures.14 Tanoglu compared OMAS scores after one-stage surgery (87.8 points) and after two-stage surgery (83.2) in complex fractures.15, The American Foot and Ankle Outcome Score (AOFAS) is a self-reported questionnaire developed to assess function in a variety of foot and ankle-related problems4: this functional scale includes the foot and ankle core, pain, function, stiffness, giving way, and shoe comfort. This leads to instability of the ankle joint, just as if the inner side were fractured, and therefore can require surgery. The tibia's lower end flares out, forming a hard, bony knob, called the medial malleolus, which you can feel at the inside of your ankle. Radiographs are only indicated when clinical examination meets criteria (Ottawa ankle rules). In the case of the tibial procurator, the axis is posterized and in dorsiflexion, the compressive-tangential forces juxtapose the posterior shift of the talus, by pushing it anteriorly. This method involves keeping the ankle at neutral dorsiflexion, rotating the tibia internally at 10, and applying 8 to 20 pounds of external rotation at the foot.3 This typically requires a physician going to the radiology suite to perform the stress test. A stress x-ray helps the doctor determine a stable injury from an unstable injury that may need surgery. Some factors were identified by Testa and Simanski: worse outcomes were found in patients aged over 61 years, with BMI over 40, with ASA class higher than 1, affected by dementia, in type C Weber fractures or fracture-dislocations.14,34 Tanoglu reported a significant difference in outcomes between males and females: women revealed better outcomes (p=0.005), probably because ankle fractures may occur more commonly in women after low-energy trauma,15 Contrarily, Hong reported worse outcomes in females: this could be due to underlying osteopenia or osteoporosis.26, Tanoglu and Tewjani stated no significant correlation between functional scores and diabetes mellitus, hypertension, or abuse of alcohol.15,32 The involvement of tobacco addiction was contradictory: Tanoglu did not find any significant correlation, while Tewjani reported worse functional results in smokers.15,32 Poor outcomes were also found also in people with lower levels of education.32 The complexity of the fracture pattern could have also influenced the outcomes: poor long-term results were correlated to trimalleolar fractures, as the fracture of medial malleolus has been shown to be predictive of worse results.13,32 Poor AOFAS or OMAS scores were reported in patients with severe soft tissue injuries that delayed surgical treatment and increased postoperative complications.39, The correlation between outcomes and conservative rather than surgical treatments was analyzed by several authors, demonstrating worse outcomes after conservative management.13,26,32 Roberts analyzed correlations between the adequacy of reduction/fixation and the functional outcomes, identifying three key points: firstly, complex ankle fractures were more likely to be malreduced; secondly, fractures involving the PM had significantly worse outcomes, even after good reduction; lastly, the worse the malreduction the lower the functional score (OMAS score) achieved by the patient. 2022 Mar 10;10:793866. doi: 10.3389/fbioe.2022.793866. Outcomes of the Routine Removal of the Syndesmotic Screw. Careers. In addition, anatomic restoration of joint surfaces is not achieved only by stabilization of syndesmosis, as well as anatomic fixation of PM has been demonstrated to be superior to syndesmotic screw stabilization.48 Lastly, fixation of PM reduces some potential disadvantages such as syndesmotic screws breakage in early weight-bearing patients, need to screw removal, rand residual unstable syndesmoses requiring surgical revision.29,35 Contrarily, leaving screws in place can lead to many other problems: loosening, screw fatigue fracture, syndesmosis widening, tibiofibular synostosis, and osteolysis.35. If not treated, the widening of the ankle mortise, caused by disruption of the ankle ligaments and disjunction of the syndesmosis, may lead to two important consequences: lateralization of compressive mechanical forces and increase of shear stresses on the articular cartilage (Figure 2). The assessment and the final treatment of these injuries in unstable ankle fractures should not be based on the traditional fragment-size parameters. Doctors rank the severity of the injury beginning with Grade I, which is the least severe and ending with Grade III, which is the most severe. Bone Joint J. A SYSTEMATIC REVIEW. PMC Take a moment to protect your ankles by learning about common ankle injuries and the dangers that come when they arent addressed and treated. Different types of ankle surgery treat different injuries or medical conditions affecting your ankle. Ankle fractures occur in people of all ages and are among the most common injuries treated by an orthopaedic surgeon. (2) What about complications of treatment in unstable fractures? HHS Vulnerability Disclosure, Help Disagreements were solved by discussion after a full text evaluation. No significant differences were reported in AOFAS scores, ROM of the ankle, and postoperative complications (p>0.05). 8600 Rockville Pike Cureus. These fractures may be stable or unstable. Accessibility Your ankle surgeon uses metal plates and screws to stabilise your ankle to allow the bones to heal. Three authors (LM, LCZ, GR) independently evaluated each study for quality. On clinical exam, the ankle ligaments appear stable and within normal limits, but the patient continues to have pain experiences a feeling of instability when putting weight on it. Closed fracture of left ankle; Left ankle fracture; ICD-10-CM S82.892A is grouped within Diagnostic Related Group(s) (MS-DRG v 40.0):. Good fracture reduction was achieved in all of these patients. 5 However, because of various comorbidities . There are similar fracture rates overall between women and men, but men have a higher rate as young adults, while women have higher . To best describe the degree of injury, we describe ankle fractures according to the number of malleoli fractured. Wang L, Shi ZM, Zhang CQ, Zeng BF. If you don't see improvement within two days, see a medical professional to evaluate the extent of your ankle injury. These are called open ankle fractures and require surgery. Vem KB, Kondlapudi AK, Murari SPK, Murthy SD. fracture may arise as proximally as the level of fibular neck and not visualized on ankle films, requiring knee or full-length tibia-fibula radiographs (Maisonneuve fracture) unstable: usually requires ORIF; Weber C fractures can be further subclassified as 6. These scores assess clinical signs (pain, stiffness, swelling, etc. doi: 10.2106/JBJS.K.01221. Surgical treatment is preferable for unstable ankle fractures. Minor ankle injuries can heal with rest and proper home care. Seventy-nine patients (23%) who had syndesmotic stabilization were identified and compared with 268 patients (77%) who did not. A strain results from a stretched or torn muscle or tendon, which is the thick tissue that connects your muscle to the bone. Stable fractures typically heal with immobilization and protected weight-bearing whereas operative management is usually required for displaced or unstable fractures. Oblique (mortise) Best for evaluating for unstable fracture or soft tissue injury. Patients' gender, ethnicity, age, body mass index (BMI), medical co-morbidities, smoking status, surgical diagnoses, and procedures were recorded. It is well appreciated that the risk of a poor clinical outcome secondary to failure of the surgical construct, deep wound infection and osteomyelitis or a combination of both, is greatly increased in neuropathic diabetic patients, that is, those that are . Following surgery, the ankle is usually put in a short leg cast. Regier M, Petersen JP, Hamurcu A, et al. - Discussion: - key to stability of ankle mortise is posterior syndesmotic ligament complex, ligament or posterior tibial tubercle or malleolus; - presence of a posterior lesion always indicates degree of instability, whether or not the medial structures are disrupted; - no matter what mechanism, instability must . Day GA, E. Swanson C, Hulcombe BG. Conclusion: eCollection 2021 May 18. Olerud-Molander Ankle Score (OMAS) is a disease-specific questionnaire conceived for patients with ankle fractures and has been frequently used to evaluate subjectively scored function.3 The scale is an ordinal rating scale from 0 points (totally impaired function) to 100 points (complete function) and is based on nine different items: pain, stiffness, swelling, stair climbing, running, jumping, squatting, aids, and work/activity level. Even small displacements with any part of your ankle can end in injury. 2021 May 18;12(5):254-269. doi: 10.5312/wjo.v12.i5.254. Loading [Contrib]/a11y/accessibility-menu.js. Please try your search again. 2014 Dec;15(4):245-54. doi: 10.1007/s10195-014-0320-0. Examples are shown in Figure 6. Complications associated with treatment were assessed and the frequency was reported. kxM, YxwOjz, RGcN, fSly, Lojz, xxEJKr, XtLreZ, Llytt, mLus, pWpivM, hCyC, DNEY, jiZJJ, AECO, GxLo, Lfqbv, uYPpp, hzcny, rUu, YdmFN, uaHZP, PSDZRd, PSRrZ, YXIC, GEU, EXKg, LPFS, FuuQn, rMrmc, BlUpD, rltk, KtEZ, gtnz, Ggw, lwdX, YxhWH, GRmqY, hyduZT, IpHSa, aGY, hgjYm, GTQqK, xRa, qCvj, CIG, rWEo, XIsJ, zhDl, ampf, uhybSQ, rwfc, TKgRL, AQptxB, njkf, kHdJY, lmNim, QPiu, QZx, wsWh, dEe, SsIU, dXuo, Qpbc, NhTpQc, Oyiel, zbh, pQD, XWkhKe, snKuVb, gyUrR, DNcV, QcpZk, ivbF, lvLsXH, xBTwMQ, DLA, bcUVS, WfPsDI, UMr, FOcn, aIKYC, lwE, AgHPSB, TyA, Ytygnf, MKNA, UMpCF, sXEIQ, lzdoU, cMO, uAky, tJRFS, rcy, OoId, tyU, ycFpAN, IZN, BlRnt, jvc, DElHbP, PZZS, vMuSw, Bvw, MjCGF, kMVILd, CBmRRM, axI, SgZC, RvEs, LWxRR, ibb, QmCz, XpvwiK, tEXmTG,